On September 19, 2013 at 7 p.m. the Pride Center (2040 North Dixie Highway) will host a community discussion in the main room, “The Future of Ryan White Care: Where Do We Go From Here?” Robert Boo and Kristopher Fegenbush of the Price Center will moderate. Jason King of the AIDS Healthcare Foundation, and Joey Wynn, co-chair of South Florida AIDS Network, will provide background and context.

According to Joey Wynn, this discussion will provide “an opportunity for both Ryan White Care providers and the community that deals with HIV infection to weigh in on the renewal.” While the act authorizing Ryan White Care, the largest federal program targeted to HIV care, expires on September 30, 2013, it lacks a “sunset clause” allowing the program to continue. Three political factors, however, make its renewal particularly “challenging.”

First, when Ryan White was renewed in 2009, only nine House members voted against it, but Ron Paul was among those nine. The growth of the Tea Party indicates the increasing strength of his brand of conservatism. Second, the bill is up for renewal amidst serous budget battles. Third, the Supreme Court ruling that states could opt out of the Medicaid Expansion of Health Care Reform has created a two-tiered system of HIV care in the US.

The Ryan White Care Act will expire along with the entire federal budget on September 30, 2013. If, by the end of the month, Congress fails to either pass a budget or a continuing budget resolution, the federal government will have to begin to shut down. Generally, congress has passed continuing resolutions while negotiating the details of an actual budget, but the failure to pass a continuing resolution in 1995-1996 led to the last government shutdown. At some point in October or November, Congress will vote to default on its debts or to raise the debt ceiling to pay its debts. The threat to default in 2011 led to the downgrading of the credit rating of the U.S.

Originally, Health Care Reform would have had almost all Ryan White Care clients migrate to either an expanded Medicaid or the Health Exchanges. As the bulk of Ryan White Care payments are for medical services and HIV medications, this migration to an expanded Medicaid and the Exchanges would free up large amounts of money to fund services to help people stay in treatment and to improve adherences to medication schedules.

The Supreme Court, however, ruled that states could opt out of Medicaid expansion. As of press time, 25 states, including Florida, have opted out of Medicaid expansion, creating a two-tiered system of HIV care. In the expanded Medicaid states, Ryan White Care will pay for insurance premiums, copays, and support services, but in the non-expanded Medicaid states, like Florida, Ryan White Care will continue to pay for HIV medical and pharmaceutical expenses. The division between expanded and non-expanded Medicaid states roughly matches the division between “blue” and “red” states.

HIV is also increasing in the “red” states. According to Jason King of AIDS Healthcare Foundation, more than half of all new HIV infections are occurring in the largely “red” South. He continued “The South is not getting its fair share under the current method” of allocating RWC funds.

Previously at each renewal, disagreements occurred over how to allocate the funds to different states. The two-tier system makes a fair allocation of resources between expanded Medicaid and non-expanded Medicaid states very complex and difficult. While everyone can agree that it should be fair, people regularly disagree over what is fair.

Given the high rates of HIV infection among gay/bi and other men who have sex with men, the renewal of Ryan White Care may be the piece of legislation before Congress with the most impact on the LGBT community. And that requires that the community pay close attention to it.